=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669470134
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOLIVEN C BAUTISTA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2005
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 N MAYFAIR RD FL 4
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-4216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-259-7246
-----------------------------------------------------
Fax | 414-259-7544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3106 WEDGEWOOD DR
-----------------------------------------------------
City | COLGATE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53017-9570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-732-1503
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 44156-020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------